Neck dissection for non-squamous malignancy

Of 1030 patients who underwent neck dissection (radical, modified or selective) in a 27-year period 103 had malignant neck nodes from a primary site in the head and neck with a histological diagnosis other than squamous carcinoma. There were 71 men and 32 women in this group with a mean age of 55 years. 28 patients had neck dissection as part of their initial treatment and 75 for later nodal recurrence. Five-year survival was 52% (40-63%). Survival was site dependent, best for thyroid tumours and worst for tumours of the major salivary glands (χ2/1 = 6.52, P < 0.05). Histology significantly affected survival, best for papillary tumours and worst for melanoma and undifferentiated tumours (χ2/1 = 3.85, P < 0.05). Survival was worse with advanced N stage but varied little with node level. The number of nodes invaded had a highly significant effect on survival (χ2/1= 23.94, P < 0.001), but extracapsular rupture had no effect. Advanced T stage at the time of surgery had a significant adverse effect on survival using univariate analysis, but this effect disappeared using multivariate analysis. In the 75 patients who had neck dissections for nodal recurrence the presence of a simultaneous recurrence at the primary site had no significant effect on survival. These patients had a better 5-year survival than patients having neck dissection for squamous disease, but the usual predictors of survival in squamous carcinoma do not always apply to non-squamous malignancy. Keywords head and neck cancer non-squamous neck dissection survival     

Neck dissection complications

Because of the proximity of vital structures, certain complications are inherent to neck dissection (ND) for the treatment of patients with squamous cell carcinoma of the upper aerodigestive tract.Aim: To establish the incidence of complications of ND.Methods: A cross-sectional retrospective study of patient registries. ND with curative intention was evaluated in 480 patients with squamous cell carcinoma of the upper aerodigestive tract from January 1995 to December 2008 to identify perioperative complications.Results: Considering the total quantity of dissected neck sides, 413 radical ND and 295 selective ND were studied, of which 220 were supraomohyoid ND and 75 were jugular ND, totaling 708 sides. There were no deaths. The most frequent complication was marginal mandibular nerve injury (5.5%), followed by accessory nerve injury (5.1%). However, in 18 out of 21 cases this nerve was sacrificed for oncological completeness.Conclusions: There were no perioperative deaths. Nerves were the most commonly injured structures; the marginal mandibular branch is injured most (5.5%).     

喉癌cNO患者颈淋巴清扫术及术式选择

喉癌的颈淋巴转移及N分期是影响疗效与预后的重要独立因素,有颈淋巴转移者生存率明显降低,因此,喉癌的治疗须同时考虑对其颈淋巴结的处理,其处理策略与治疗方式的选择是一个颇为棘手的问题[1-2].     

喉癌cNO患者颈淋巴清扫术及术式选择

喉癌的颈淋巴转移及N分期是影响疗效与预后的重要独立因素,有颈淋巴转移者生存率明显降低,因此,喉癌的治疗须同时考虑对其颈淋巴结的处理,其处理策略与治疗方式的选择是一个颇为棘手的问题[1-2].     

喉癌cNO患者颈淋巴清扫术及术式选择

喉癌的颈淋巴转移及N分期是影响疗效与预后的重要独立因素,有颈淋巴转移者生存率明显降低,因此,喉癌的治疗须同时考虑对其颈淋巴结的处理,其处理策略与治疗方式的选择是一个颇为棘手的问题[1-2].     

Neck dissection and combined therapy. Study of effectiveness

Data on 1,385 neck dissections in 1,192 patients were studied to evaluate the effectiveness of treatment with operation alone and with various forms of combined therapy in controlling cervical metastasis. Of the 1,192 patients, 837 were treated by operation (neck dissection) alone, and the remainder had preoperative or postoperative radiation to the primary site and to the entire side of the neck that was dissected. In no stage of neck disease was either form of combined therapy superior to operation alone in decreasing the rates of recurrence. In an attempt to simulate a randomized, prospective study in a clinical situation for which the end results were already known, we used a separate statistical analysis--a case-control technique to specifically address the issue of the effectiveness of postoperative radiation in decreasing the frequency of recurrences after dissection in the various stages of disease. No evidence of a relationship between recurrence and the administration of planned postoperative radiation was found.     

Neck dissection with simultaneous carotid endarterectomy

Background: Patients with metastatic neck disease from upper aerodigestive tract carcinomas have an extensive history of tobacco and alcohol abuse. These patients are predisposed to develop atherosclerotic vascular disease. Objective: An increased incidence and severity of carotid stenosis in patients receiving radiotherapy for head and neck cancers is known. Management of patients with severe carotid stenosis who require surgical treatment of their neck disease has not been described. The authors describe our experience with simultaneous carotid endarterectomy and neck dissection. Study Design: Prospective data collection. Methods: From 1991 to 1997 at West Virginia University Hospitals, Morgantown, West Virginia, and State University of New York (SUNY) at Buffalo, three patients with severe carotid stenosis required surgery for metastatic neck disease. Preoperative evaluation revealed a bilateral carotid stenosis greater than 90% in all patients. All patients underwent modified radical neck dissections and simultaneous carotid endarterectomies with saphenous vein grafting. Two patients, one undergoing partial pharyngectomy and laryngectomy and the other a laryngectomy and neck dissection, had coverage of the carotid artery with the myogenous component of a pectoral major graft. One patient had only a neck dissection. Results: Two patients healed with no local morbidity, no neck recurrence, and a patent carotid artery by Doppler. No strokes were encountered. One patient died of a myocardial infarction. Conclusion: Severe carotid stenosis that requires revascularization may have endarterectomy performed simultaneously with treatment of head and neck primary with no increase in morbidity.     

分化型甲状腺癌颈淋巴结清扫术

分化型甲状腺癌(differentiated thyroid cancer,DTC)起源于甲状腺滤泡上皮细胞,占甲状腺癌的90％以上,主要包括甲状腺乳头状癌(papillary thyroid carcinoma,PTC)和甲状腺滤泡状癌(follicular thyroid carcinoma,FTC),少数为Hurthle细胞或嗜酸性细胞肿瘤.颈部淋巴结转移是PTC主要的生物学特性之一,约20％ ～90％ PTC诊断时病理证实颈部淋巴结转移,转移部位最常见为同侧颈Ⅵ区淋巴结.甲状腺癌患者的颈部淋巴结转移,是复发率增高、存活率降低的危险因素.低分化型甲状腺癌也属于分化型甲状腺癌范畴,此类型肿瘤的临床生物学特点为高侵袭性、易转移、预后差.     

Neck dissection in squamous cell carcinoma of the larynx. Indication of elective contralateral neck dissection

Unilateral or bilateral neck dissection must be considered in the treatment of laryngeal cancerAimTo evaluate the prevalence of contralateral metastases in larynx cancer and distribution of these metastases according to lymph node levels in the neck.MethodRetrospective longitudinal study of 272 charts from patients with squamous cell cancer of the larynx treated between 1996 and 2004; and we selected 104 surgical cases submitted to neck dissection. We evaluated the incidence of bilateral or contralateral metastases, according to the location and extension of the primary tumor, considering the anatomical sub-sites and the midline.ResultsContralateral metastases in lateral tumors were observed in 3.5% of glottic lesions and in 26% of supraglottic lesions. Contralateral metastases were uncommon in N0 patients. Lymph nodes levels IIa and III were the most commonly involved in the neck.ConclusionIn lateral glottic tumors there is no need for elective contralateral neck dissection. In supraglottic lesions without ipsilateral metastases, the incidence of hidden metastasis does not justify elective contralateral dissection. The midline is not a reliable indicator of the risk of contralateral laryngeal tumors.     

Neck dissection: present and future?

A number of issues are at the forefront of current considerations in surgical treatment of the neck in head and neck cancer. These include proposed new definitions of lymph node levels that will lend themselves to clinical and radiographic examination, the possibility of employing molecular studies to supply information on the metastatic potential of the primary tumor in the clinically negative neck, and the results of multi-institutional prospective pathologic studies of neck dissection specimens examining the early distribution of lymph node metastases from various primary sites, to design more effective and efficient surgical procedures for treatment. The pertinent current literature was reviewed, and appropriate data extracted. Various new landmarks have been defined to distinguish the boundaries between sublevels IB and IIA, the lateral borders of level VI, and the boundaries of level VII. These landmarks are more readily distinguishable on physical and radiographic examination than the definitions currently in use. Numerous molecular studies have been employed to detect subclinical metastatic deposits in the neck, but none have been found sufficiently reliable for practical application. Multi-institutional studies have shown that sublevels IIB and level IV are rarely within the first level of lymphatic drainage routes for most primary squamous cell cancers of the head and neck. Therefore, elective selective neck dissections may be further modified to reduce morbidity and operating time. Various new issues in the treatment of cervical metastatic disease are discussed in an effort to improve the accuracy of pretreatment staging, identification of occult disease, and modification of surgical treatment to optimize efficiency and reduce morbidity.     

Lebensbedrohliche und letale Komplikationen der Neck dissection

BACKGROUND: Between 1990 and 1999, 395 neck dissections were performed in 357 patients: 195 left-sided (105 of these radical) and 200 right-sided (107 of these radical). Life-threatening complications occurred in four cases and two patients died. CASE REPORTS: After left-sided radical neck dissection with chylous fistula, a chylothorax resulted, which could not be controlled in spite of chest tube drainage and thoracotomy so that the 75-year-old female patient died 30 days postoperatively. A 66-year-old man died 35 days after a functional neck dissection of the left side because of extreme chylous flow of up to 7 l/day in spite of parenteral nutrition, local surgical revision, and intrathoracic ligation of the thoracic duct. Undetected cirrhosis of the liver was regarded to be the reason for this extremely increased lymph flow. In a 63-year-old man, a jugular foramen hemorrhage during radical neck dissection could only be managed after 3 h and approximately 6 l of blood loss. In a 66-year-old man, a discrete injury of the pleura led to cardiovascular failure due to a tension pneumothorax with mediastinal shift about 45 min later, which required immediate chest tube placement. DISCUSSION: In none of these unusual cases, which accounted for 1% of all evaluated interventions, had the patients been informed about the observed complication. However, no legal consequences resulted. Nevertheless, dramatic courses of chylous fistulas and rare complications should be considered both forensically when seeking informed consent and clinically.